Patient’s Name: ________________________________________________________ Date: ___________________________
PATIENT INFORMATION
First Name: __________________________________________
Last Name: _________________________________ MI: _____
Address: _____________________________________________
City: _______________________ State:_______ Zip:__________
Payment is due at time of service. Payment methods accepted
are: cash, check, credit card, HSA, and FLEX Spending
Accounts. We are a cash based practice and, therefore, do not
submit claims to insurance. Superbills and receipts are available
upon request for insurance reimbursement.
Please check your perferred method of payment:
 cash, check, credit
 HSA
 FLEX Spending
Phone: ______________________________________________
Email: _______________________________________________
For Office Only
Date of Birth ____________________ Sex:  M
Height: _________ ’ _________ ”
F
 Married  Single  Partnered for ____ Years
Social Security #/DL #:_________________________________
Occupation: __________________________________________
Employer/School:____________________________________
Phone (Work): ________________________________________
Patient Vitals Date: _____/_____/_____
Weight: ____________ lbs.
Blood Pressure: ______ /______ mm/ng
Pulse: ________ BPM
Pulse Oxygen: _________ %
Workout History Information (if applicable)
Gym Name: __________________________________________
Employer/School Address: ______________________________
How long you’ve been participating in your sport: __________
Spouse’s Name: ________________________________________
Type of Exercise: ______________________________________
Spouse’s Occupation: ___________________________________
Spouse’s Birth date:_____________________________________
Who can we thank for referring you to us?
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
____________________________________________________
___________________________________________________
EMERGENCY CONTACT
FAMILY INFORMATION
Best Phone Number to reach you: (______) _________________
Children’s Name(s)
Sex
Date of Birth
Best time to reach you: _________________________________
__________________________
M F
________________
In case of an emergency, contact:
__________________________
M F
________________
Name: ____________________Relationship:________________
__________________________
M F
________________
Phone: (______) _____________ Work: (______) ______________
__________________________
M F
________________
LIFESTYLE
Exercise: Work Activity: Habits:  None  Sitting  Smoking  Moderate  Standing  Alcohol  Daily  Light Labor  Coffee/Caffeine Drinks
 Heavy
 Heavy Labor
 High Stress Level
MEDICATIONS
ALLERGIES
1._________________________________________________
1._________________________________________________
2._________________________________________________
2._________________________________________________
3._________________________________________________
3._________________________________________________
Pharmacy Name: ______________________________________
How often do they occur?
Pharmacy Phone: (___________) ________________________
____________________________________________________
VITAMINS/SUPPLEMENTS
Please list: _____________________________________________________________________________________________________
 Daily
 Weekly
 Monthly
HEALTH HISTORY
What treatment have you already received for your condition?
 Medications
 Surgery
 Physical Therapy
 Chiropractic Services
 None
 Other
________________
Name and address of other doctor(s) who have treated you for your condition:________________________________________________
Date of last: Physical Exam _________
Dental X-Ray _________
Spinal X-Ray _________
Blood Test _________
MRI, CT/Bone Scan ______
GENERAL SYMPTOMS
____
____
____
____
____
____
____
Convulsions
Dizziness
Fainting
Headache
Nervousness
Numbness
Wheezing
MUSCLES & JOINTS
____
____
____
____
____
____
____
____
____
____
____
____
____
Low Back Problems
Pain b/t Shoulders
Neck Problems
Arm Problems
Leg Problems
Swollen Joints
Painful Joints
Stiff Joints
Sore Muscles
Weak Muscles
Walking Problems
Sprains/Strains
Broken Bones
CARDIO-VASCULAR
____ High Blood Pressure
____ Heart Attack
____
____
____
____
____
____
____
____
Spinal Exam _________
Pain over Heart
Poor Circulation
Heart Trouble
Rapid Heart
Slow Heart
Strokes
Swelling Ankles
Varicose Veins
EAR/NOSE/THROAT
____
____
____
____
____
____
____
____
____
____
____
____
Earache
Ear Noises
Enlarged Thyroid
Frequent Colds
Hay Fever
Nasal Blockage
Nose Bleeds
Pain Behind Eyes
Poor Vision
Sinusitis
Sore Throats
Tonsillitis
GASTRO-INTESTINAL
____ Belching/Gas
____ Colon Problems
____ Constipation
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
Chest X-Ray _________
Diarrhea
Excessive Hunger
Excessive Thirst
Gall Bladder Trouble
Hemorrhoids
Liver/Gallbladder
Nausea
Abdominal Pain
Ulcer
Poor Appetite
Poor Digestion
Vomiting
Vomiting Blood
Black Stool
Bloody Stool
Weight Loss/Gain
RESPIRATORY
____
____
____
____
____
Asthma
Chronic Cough
Difficulty Breathing
Spitting Blood
Spitting Phlegm
GENITO-URINARY
____ Blood in Urine
____ Frequent Urination
Urine Test _________
____
____
____
____
Kidney Infection
Painful Urination
Prostate Problems
Loss of Bladder Ctrl
SKIN OR ALLERGIES
____
____
____
____
____
____
____
____
Boils
Bruising Easily
Dryness
Eczema/Dermatitis
Hives
Itching
Sensitive Skin
Allergy
FOR WOMEN ONLY
____ Birth Control
____ Hormone Replmnt
____ Cramps/Backaches
____ Excessive Flow
____ Hot Flashes
____ Irregular Cycle
____ Miscarriage
____ Painful Periods
____ Vaginal Discharge
____ Breast Pain
Pregnant at this Time: Y / N
Please list all injuries/surgeries you have had:
DescriptionDate
_______________________________________________________________ _____________________________________________
_______________________________________________________________ _____________________________________________
_______________________________________________________________ _____________________________________________
Terms of Acceptance
When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same
objective. Chiropractic only has one goal. It is important that each patient understands both the objective and the method that will be used
to attain it. This will prevent any confusion or disappointment.
Adjustment: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation. Our chiropractic
method of correction is by specific adjustments of the spine.
Health: A state of optimal physical, mental, and social well-being, not merely the absence of disease or infirmity.
Vertebral Subluxation: A misalignment of one or more of the 24 vertebrae in the spinal column which causes alteration of nerve function
and interference of the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health
potential.
Chiropractic care like all forms of health care, while offering considerable benefit may also provide some level of risk. This level of risk is
most often very minimal, yet in rare cases injury has been associated with chiropractic care. The types of complications that have been
reported secondary to chiropractic care include sprain/strain injuries, irritation of a disc condition and rarely, fractures. One of the rarest
complications associated with chiropractic care, occurring at a rate between one instance per one million to one per two million cervical
spine (neck) adjustments may be a vertebral artery injury that could lead to stroke. Prior to receiving chiropractic care from UnBroken Chiropractic, a health history and physical examination will be completed. These procedures are performed to assess your specific condition,
your overall health and, in particular, you spinal health. These procedures will assist us in determining if chiropractic care is needed, or if
any further examination or studies are needed. In addition, they will help us determine if there is any reason to modify your care or provide
you with a referral to another health care provider. All relevant findings will be reported to you along with a care plan to beginning care.
It is important to note, we do not offer to diagnose or treat any disease. We only offer to diagnose either vertebral subluxation or neuro­‐musculoskeletal conditions. However, if during the course of a chiropractic examination, we encounter non­‐chiropractic or unusual
findings, we will advise you. If you desire advice, diagnosis, or treatment for those findings, we will recommend that you seek the services of
another health care provider. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment
prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. However, we may use other procedures to help your body hold
the adjustments. I understand and accept that there are risks associated with chiropractic care and give my consent to the examinations that
the chiropractor deems necessary, and to the chiropractic care including spinal adjustments, as reported following assessment.
_______________________________________________________________________________________________________________ (Signature)
(Date)
Consent to evaluate and adjust a minor child
I,____________________________ being the parent or legal guardian of _________________________, have read and fully understand
the above terms of acceptance and hereby grant permission for my child to receive chiropractic care.
Pregnancy Release
This is to certify that to the best of my knowledge I am not pregnant and the above practice and his/her associates have my permission to
perform an x-­ray evaluation. I have been advised that x-­ray can be hazardous to an unborn child.
_______________________________________________________________________________________________________________ (Signature)
(Date)
Agreements and Authorization
Consent to Health Care Services/Release of Health Care Information
You, (the undersigned Patient, or undersigned person responsible for consenting on Patient’s behalf) hereby request and consent to Patient
health care services from UnBroken Chiropractic. The Patient health care services will be provided by licensed, treating chiropractors.
Health care services may also be provided by non‐chiropractic health care professionals employed, under contract, or otherwise retained by
UnBroken Chiropractic, nursing, and other health care professionals who are in training may also participate in the Patient’s care as part of
their education. ___________initial
Payment Guarantee
In consideration of the services provided by UnBroken Chiropractic, Provider to Patient, you agree to; I) Guarantee payment of all
charges incurred by Patient in connection with such services (“Patient Charges”); II) Being fully responsible for the payment of any and
all Patient Charges and the payment of any legal fees incurred by UnBroken Chiropractic for efforts to collect any delinquent balances of
aforementioned unpaid Patient Charges.
If you have insurance, insurance companies will only pay what is covered in each individual’s insurance policy. It is your responsibility
to work, in combination with your insurance company, to determine what, if any, chiropractic and rehabilitative therapy benefits might
be included and covered by your specific policy. If your insurance policy does not cover services rendered from this office, then you are
responsible for the non-­‐covered services at the time they are rendered. If you have a Health Savings Account (HSA), Flex Spending
Account (FSA), or a Health Reimbursement Arrangement (HRA), it’s possible that these additional benefits may be applicable to your
chiropractic care and/or rehabilitative therapy. By initialing, you acknowledge your understanding that none of these responsibilities fall to
UnBroken Chiropractic and are solely within your charge to determine and apply after fulfilling your obligation to UnBroken Chiropractic
for any/all services rendered. UnBroken Chiropractic is not responsible for any charges not covered by your insurance policy.
___________initial
Consent to Release of Information
Please Continue and Sign Consent to Release of Information
Here at UnBroken Chiropractic, we respect your privacy, we do not sell or release your information to third parties. There will be cases
along the course of your care where information will need to be released in certain circumstances. You authorize UnBroken Chiropractic to
release to employer groups, government agencies (Medicare, Medicaid, Champus, State or Federal governments, etc.), insurance companies,
or other third-­party payers and their agents, and its collection representative and attorneys, the following “Patient Information”: medical
history, diagnoses, and procedures performed, course of treatment, plan of care, prognosis, supplies and/or such other information that
may be requested for the purpose of determining eligibility and availability of Patient’s benefits, obtaining authorization/payment for the
Patient’s health care services or billing and collection of amounts due to UnBroken Chiropractic for services rendered. In the case of Patient
Information released for purposes of payment of Patient Charges, this authorization shall be valid only for the period of time necessary
to process payment claims. You agree to pay any Patient Charges that are denied or are ineligible for medical reimbursement benefits as a
result of your refusal or revocation of consent to disclose Patient Information.
You further authorize any individual health care professionals, including treating physician(s), to provide UnBroken Chiropractic, or
its designee, with Patient Information for quality assurance and/or risk management purposes. Finally, in the event that the Patient’s
employer, or an insurance company representing such employer, requests Patient Information relating to healthcare services provided for
worker’s compensation injuries, it is understood and agreed that UnBroken Chiropractic is required, under state law, to release copies of
such information to such employer or insurance company without the authorization of Patient or Patient’s representative. Again, here at
UnBroken Chiropractic we strive to provide you with the best care possible and in order to do that this consent is needed.
_________Initial
Responsibility for Personal Property
You accept sole responsibility for all Patient property, except for property expressly accepted by UnBroken Chiropractic for safekeeping
under its sole care and custody.
No revisions of changes to this form by you will be accepted by UnBroken Chiropractic
_______________________________________________________________________________________________________________
(Signature of Patient or Responsible Party: party, guardian or other representative)
(Date)
_______________________________________________________________________________________________________________
(Signature of Policy Holder)
(Relationship) (Date)
_______________________________________________________________________________________________________________
(Signature of Witness to signing of consent form)
(Date)
Patient Privacy Acknowledgment
For use and/or disclosure of Protected Health Information (PHI) to carry out Treatment, Payment, and Healthcare Operations
I,______________________________ hereby state that by signing this Consent I acknowledge and agree as follows:
1) The Practice’s Privacy Notice has been provided to me prior to my signing this consent. The Privacy Notice includes a
complete description of the uses and/or disclosures of my protected health information (“PHI”) necessary for the Practice to
provide treatment to me, and also necessary for the Practice to obtain payment for that treatment and to carry out its health
care operations. The Practice explained to me that the Privacy Notice would be available to me in the future at my request.
The Practice has further explained my right to obtain a copy of the Privacy Notice prior to signing this Consent, and has
encouraged me to read the Privacy Notice carefully prior to my signing this Consent.
2) The Practice reserves the right to change its privacy practices that are described in its Privacy Notice, in accordance with
applicable law.
3) This Notice of Privacy Practices also describes my rights and the duties of this office with respect to my protected health
information.
I have read and understand the foregoing notice, and all my questions have been answered to my full satisfactions in a way that I can understand.
_______________________________________________________________________________________________________________
(Printed Name)(Signature)(Date)
_______________________________________________________________________________________________________________
(Signature of Legal Representative)
(Relationship) (Date)
_______________________________________________________________________________________________________________
(Witness - office personnel)
(Date)
Name:Date of Birth:
Main Problem
Second Problem
Other Problems
In each space provided below, please rate how bad each problem is TODAY on a scale of 1-10
/10
Problem #1:
/10
Problem #2:
/10
Problem #3:
How would you describe the pain for each problem (check all that apply)
 sharp/stab
dull/ache
 burning
 sharp/stab
dull/ache
 burning
 sharp/stab
dull/ache
 burning
 numb
 tingling
 radiating
 numb
 tingling
 radiating
 numb
 tingling
 radiating
 other ___________________________
 other ___________________________
 other ___________________________
What percentage of the time during the day do you notice each problem?
10% 20% 30% 40% 50%
60% 70% 80% 90% 100%
10% 20% 30% 40% 50%
60% 70% 80% 90% 100%
10% 20% 30% 40% 50%
60% 70% 80% 90% 100%
What time of day does each problem feel the WORST?
 morning
 afternoon
 morning
 afternoon
 morning
 afternoon
 evening
 before bed
 evening
 before bed
 evening
 before bed
On a scale of 1-10, how bad is each problem when it feels the WORST?
/10
Problem #1:
Problem #2:
/10
Problem #3:
/10
On a scale of 1-10, how bad is each problem when it feels the BEST?
Problem #1:
/10
Did Problem #1 Start:
Problem #2:
/10
Did Problem #2 Start:
 suddenly -OR-  gradually
 suddenly -OR-  gradually
Problem #3:
/10
Did Problem #3 Start:
 suddenly -OR-  gradually
How long ago did each problem begin? (Tell us the # of days/weeks/months/years you have had it)
Since you first noticed each problem, is it getting better, worse, or staying the same?
 better  worse  same
 better  worse  same
 better  worse  same
Activities of Daily Living - Please indicate 1, 2, or 3 for which “problem” pain is most affected by each activity. If none, leave blank.
____ bending
____ jumping
____ sex
____ carrying
____ kneeling
____ sitting
____ climbing
____ lifting
____ sleeping
____ cooking
____ laying
____ sneezing
____ computer ____ coughing
____ pulling
____ pushing
____ standing ____ turning
____ dressing
____ reaching
____ twisting
____ driving
____ running
____ walking
Please indicate 1, 2, or 3 for which of the following decreases pain for that specified “problem”. If unsure, leave blank.
____ acupuncture
____ medication
____ foam rolling
____ proper technique
____ heat
____ rehabilitation therapy
____ ice
____ massage
____ RockTape/kinesiology ____ stretching
Additional Activities of Daily Living Please indicate 1, 2, or 3 for which “problem” pain is most affected by each activity. If none, leave blank.
____ stairs - circle one
climbing
descending
____ squats - circle one
air squats
squatting w/weight
front squat
____ snatch - circle one
power snatch
full squat snatch
high hang
____ clean and jerk - circle one
power clean
full squat clean
____ kettle bell swings
____ kettle bell snatches
____ deadlifts
____ sit-ups
____ hand stand push-ups
____ hand stand holds
____ wall balls
____ rope climbs
____ box jumps
____ lateral movements
____ pull ups
high hang
back squat
mid hang
mid hang
overhead squat
low hang
low hang
set up
set up
____ ring muscle ups
____ bar muscle ups
____ dips
____ burpees
____ rowing
____ biking
____ running
____ double unders
____ push ups
____ bench press
____ stone to shoulder
____ isolated exercise - describe: _____________________________________________________________________________________
____ your sport: - describe: _________________________________________________________________________________________
____ other: - describe: _____________________________________________________________________________________________